IIUsing the recommendations

2.1. Background

The Medical eligibility criteria for contraceptive use (MEC) provides guidance regarding which clients can use contraceptive methods safely. The goal of the document is to improve access to, and quality of, family planning services by providing policy-makers, decision-makers and the scientific community with recommendations that can be used for developing or revising national guidelines on the medical eligibility criteria for the use of specific contraceptive methods. Methods covered by this guidance include all hormonal contraceptives, intrauterine devices, barrier methods, fertility awareness-based methods, coitus interruptus, lactational amenorrhoea method, male and female sterilization, and emergency contraception. These evidence-based recommendations do not indicate a “best” method that should be used in a particular medical context; rather, review of the recommendations allows for consideration of multiple methods that could be used safely by people with certain health conditions (e.g. hypertension) or relevant characteristics (e.g. age).

2.1.1. Reproductive and sexual health care as a human right

The Programme of Action of the International Conference on Population and Development (ICPD) defines reproductive health as: “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes”1. The Programme of Action also states that the purpose of sexual health “is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases”. Recognizing the importance of agreements made at the ICPD and other international conferences and summits, the Beijing Declaration and Platform for Action defines reproductive rights in the following way:

Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other relevant consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number and spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.2

Among the Millennium Development Goals (MDGs) agreed by states in 2001, target 5b calls for universal access to reproductive health by 2015. Reproductive and sexual health care, including family planning services and information, is recognized not only as a key intervention for improving the health of men, women and children but also as a human right. International and regional human rights treaties, national constitutions and laws provide guarantees specifically relating to access to contraceptive information and services. These include the guarantee that states should ensure timely and affordable access to good quality sexual and reproductive health information and services, including contraception, which should be delivered in a way that ensures fully informed decision-making, respects dignity, autonomy, privacy and confidentiality, and is sensitive to individuals' needs and perspectives in a client–provider partnership.3 A rights-based approach to the provision of contraceptives assumes a holistic view of clients, which includes taking into account clients' sexual and reproductive health care needs and considering all appropriate eligibility criteria when helping clients choose and use a family planning method safely.

Evidence shows that the respect, protection and fulfilment of human rights contribute to positive health outcomes. The provision of contraceptive information and services that respect individual privacy, confidentiality and informed choice, along with a wide range of safe contraceptive methods, increase people's satisfaction and continued use of contraception.4 5 6 7

Delivery of care in accordance with the client's human and reproductive rights is fundamental to quality of care. The development of international norms for medical eligibility criteria and practice recommendations for contraceptive use is only one aspect of improving the quality of reproductive health care. Many family planning programmes have included screening, treatment and follow-up procedures that reflect high standards of public health and clinical practice, but these should not be seen as eligibility requirements for specific contraceptive methods. These procedures include the screening and treatment of cervical cancer, anaemia and sexually transmitted infections (STIs), and the promotion of breastfeeding and cessation of smoking. Such procedures should be strongly encouraged if the human and material resources are available to carry them out, but they should not be seen as prerequisites for the acceptance and use of family planning methods since they are not necessary to establish eligibility for the use or continuation of a particular method.

2.1.2. Contraceptive choice

While this document primarily addresses medical eligibility criteria for contraceptive use, considerations of social, behavioural and other non-medical criteria – particularly client preference – must also be taken into account. To provide contraceptive choices to clients in a way that respects and fulfils their human rights necessitates enabling clients to make informed choices for themselves. Women's choices, however, are often taken away from them or limited by direct or indirect social, economic and cultural factors. From a woman's point of view, her choices are made at a particular time, in a particular societal and cultural context; choices are complex, multifactorial and subject to change. Decision-making regarding contraceptive methods usually requires the need to make trade-offs among the advantages and disadvantages of different methods, and these vary according to individual circumstances, perceptions and interpretations. Factors to consider when choosing a particular contraceptive method include the characteristics of the potential user, the baseline risk of disease, the adverse effects profile of different products, cost, availability and patient preferences.

This document does not provide recommendations about which specific product or brand to use after selecting a particular type of contraceptive method. Instead, it provides guidance for whether women with specific medical conditions or medically relevant physiological or personal characteristics are eligible to use various contraceptive methods. Decisions about what methods to use should also take into account clinical judgment and user preferences.

Issues of service quality and access that affect method use and choice

The following service-delivery criteria are universally relevant to the initiation and follow-up of all contraceptive method use:

  • Clients should be given adequate information to help them make an informed, voluntary choice of a contraceptive method. This information should at least include:

    the relative effectiveness of the method;

    correct usage of the method;

    how it works;

    common side-effects;

    health risks and benefits of the method;

    signs and symptoms that would necessitate a return to the clinic;

    information on return to fertility after discontinuing method use; and

    information on STI protection.

    Information should be presented using language and formats that can be easily understood and accessed by the client.
  • In order to offer methods that require surgical approaches, insertion, fitting and/or removal by a trained health-care provider (i.e. sterilization, implants, IUDs, diaphragms, cervical caps), appropriately trained personnel in adequately equipped and accessible facilities must be available, and appropriate infection-prevention procedures must be followed.
  • Adequate and appropriate equipment and supplies need to be maintained and held in stock (e.g. contraceptive commodities, and supplies for infection-prevention procedures).
  • Service providers should be provided with guidelines, client cards or other screening tools.

2.1.3. Effectiveness of method

Contraceptive choice is in part dependent on the effectiveness of the contraceptive method in preventing unplanned pregnancy, which, in turn, is dependent for some methods not only on the protection afforded by the method itself, but also on how consistently and correctly it is used. Table 2.1 compares the percentage of women experiencing an unintended pregnancy during the first year of contraceptive method use when the method is used perfectly (consistently and correctly) and when it is used typically (assuming occasional non-use and/or incorrect use). Consistent and correct usage can both vary greatly with client characteristics such as age, income, desire to prevent or delay pregnancy, and culture. Methods that depend on consistent and correct usage by clients (e.g condoms and pills) have a wide range of effectiveness. Most men and women tend to be more effective users as they become more experienced with a method. However, programmatic aspects also have a profound effect on how effectively (consistently and correctly) the method will be used.

Table 2.1. Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year, United States.

Table 2.1

Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year, United States.

2.1.4. Conditions that expose a woman to increased risk as a result of unintended pregnancy

Women with conditions that may make unintended pregnancy an unacceptable health risk should be advised that, because of their relatively higher typical-use failure rates, sole use of barrier methods for contraception and behaviour-based methods of contraception may not be the most appropriate choice for them. These conditions are noted in Box 2.1.

Box Icon

Box 2.1

Conditions that expose a woman to increased health risk as a result of unintended pregnancy. Breast cancer Complicated valvular heart disease

2.1.5. Return to fertility

Among contraceptive methods, only male and female sterilization are regarded as irreversible (or permanent). All other methods are reversible, usually with prompt return to fertility upon method discontinuation, with the exception of depot medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN). The median delay in return to fertility with these methods is 10 and 6 months, respectively, from the date of the last injection, regardless of the duration of their use. Male and female sterilization should be regarded as permanent methods (no possibility of future childbearing), and all individuals and couples considering these methods should be counselled accordingly. No other methods result in permanent infertility.

2.1.6. STIs and contraception: dual protection

In addition to the imperative of international norms for contraceptive provision to assure quality of care in services, the social, cultural and behavioural context of each client must also be considered. In this regard, the problems of exposure to STIs, including HIV, deserve special consideration because of the equal importance of preventing pregnancy and preventing transmission of infections among sexually active clients of reproductive age. When a risk of HIV and other STI transmission exists,8 it is important that health-care providers offer information on safer sexual practices to prevent transmission and strongly recommend dual protection to all persons at significant risk, either through the simultaneous use of condoms with other methods or through the consistent and correct use of condoms alone for prevention of both pregnancy and STIs, including HIV. Women and men seeking contraceptive advice must always be reminded of the importance of condom use for preventing the transmission of STI/HIV and such use should be encouraged and facilitated where appropriate. When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.

2.2. How to use this document

The present document is intended for use by policy-makers, family planning programme managers and the scientific community. It aims to provide guidance to national family planning and reproductive health programmes in the preparation of guidelines for delivery of contraceptive services. It is not meant to serve as the actual guidelines but rather as a reference.

The guidance in this document is intended for interpretation at country and programme levels in a manner that reflects the diversity of situations and settings in which contraceptives are provided. While it is unlikely that the classification of categories in this document would change during this process, it is very likely that the application of these categories at country level will vary. In particular, the level of clinical knowledge and experience of various types of providers and the resources available at the service-delivery point will have to be taken into consideration.

Recommendations are presented in tables according to the contraceptive methods included in the guidance with each condition. Each condition was defined as representing either a known pre-existing medical/pathological condition (e.g. diabetes, hypertension) or a medically relevant individual characteristic (e.g. age, history of pregnancy).

It is expected that national and institutional health-care and service-delivery environments will decide the most suitable means for screening for conditions according to their public health importance. Client history will often be the most appropriate approach. A family planning provider may want to consult an expert in the underlying condition.

Initiation and continuation

The medical eligibility criteria for the initiation and continuation of all contraceptive methods are used in the evaluation of eligibility. The assessment of continuation criteria is clinically relevant whenever a woman develops the condition while she is using the method. Where medical eligibility for initiation and continuation of a contraceptive method differ, these differences are noted in the columns of the tables for each contraceptive method (I = initiation; C = continuation). Where I and C are not denoted, the category is the same for initiation and continuation of use.

As shown in Table 2.2 in a simplified template of the tables for each contraceptive (provided in section 2.7), the first column indicates the conditions (each in a separate row). Several conditions are subdivided to differentiate between varying degrees of the condition. The second column classifies the condition for initiation and/or continuation into one of the four MEC categories, as described in section 2.3. The third column provides space for any necessary clarifications or presentation of evidence regarding the classification

Table 2.2. Template of contraceptive method tables.

Table 2.2

Template of contraceptive method tables.

2.3. Using the categories in practice

Categories 1 and 4 are self-explanatory. Classification of a method/condition as Category 2 indicates the method can generally be used, but careful follow-up may be required. However, provision of a method to a woman with a condition classified as Category 3 requires careful clinical judgement and access to clinical services; for such a woman, the severity of the condition and the availability, practicality and acceptability of alternative methods should be taken into account. For a method/condition classified as Category 3, use of that method is not usually recommended unless other more appropriate methods are not available or acceptable. Careful follow-up will be required.

Where resources for clinical judgment are limited, such as in community-based services, the four-category classification framework can be simplified into two categories. With this simplification, a classification of Category 1 or 2 indicate that a woman can use a method, and a classification of Category 3 or 4 indicate that a woman is not medically eligible to use the method (see Table 2.3).

Table 2.3. Interpretation and application of the categories in practice.

Table 2.3

Interpretation and application of the categories in practice.

Medical eligibility criteria (MEC) categories for contraceptive use

Category 1A condition for which there is no restriction for the use of the contraceptive method
Category 2A condition where the advantages of using the method generally outweigh the theoretical or proven risks
Category 3A condition where the theoretical or proven risks usually outweigh the advantages of using the method
Category 4A condition which represents an unacceptable health risk if the contraceptive method is used

2.4. Programmatic implications

The following issues need to be addressed when applying the medical eligibility criteria in this document to programmes:

  • informed choice
  • elements of quality of care
  • essential screening procedures for administering the methods
  • provider training and skills
  • referral and follow-up for contraceptive use as appropriate.

Service-delivery practices that are essential for the safe use of the particular contraceptive method should be distinguished from practices that may be appropriate for good health care but are not related to use of the method. The promotion of good health-care practices unrelated to safe contraception should be considered neither as a prerequisite nor as an obstacle to the provision of a contraceptive method, but as complementary to it.

As a next step, the recommendations on medical eligibility criteria need to be considered in light of the country context, so as to be applicable to providers at all levels of the service-delivery system. It is expected that national and institutional health-care and service-delivery environments will decide the most suitable means for screening for conditions according to their public health importance. Client history will often be the most appropriate approach. A family planning provider may want to consult an expert in the underlying condition. Countries will need to determine how far and by what means it may be possible to extend their services to the more peripheral levels of the health system. This may involve upgrading both staff and facilities where feasible and affordable, or it may require or a modest addition of equipment and supplies, and redeployment of space. It will also be necessary to address misperceptions sometimes held by providers and users about the risks and side-effects of particular methods, and to look closely at the needs and perspectives of women and men in the context of informed choice.

Adaptation is not always an easy task and is best done by those well acquainted with prevailing health conditions, behaviours and cultures. These improvements must be made within the context of users' informed choices and medical safety.

2.5. Clients with special needs

2.5.1. People with disabilities

According to United Nations Convention on the Rights of Persons with Disabilities (CRPD), people with disabilities must have access, on an equal basis with others, to all forms of sexual and reproductive health care (Article 25) as part of the general right to marry, found a family and retain their fertility (Article 23)9. Health-care professionals often fail to offer sexual and reproductive health services to people with disabilities, based on the common misconception that they are not sexually active.10 Provision of contraceptive services to people with disabilities may, however, require decisions regarding appropriate contraception considering the preferences of the individual, the nature of the disability and the specifics of different conceptive methods.

For example, some barrier methods may be difficult to use for those with limited manual dexterity; COCs may not be an appropriate method for women with impaired circulation or immobile extremities, even in the absence of known thrombogenic mutations, because of concerns about an increased risk of DVT; and other methods will be preferable for individuals with intellectual or mental health disabilities who have difficulty remembering to take daily medications. For women who have difficulty with menstrual hygiene, the impact of the contraceptive method on menstrual cycles should also be considered.

In all instances, medical decisions must be based upon informed choice, based on adequate sexual and reproductive health education. When the nature of the disability makes it more challenging to discern the will and preferences of the individual, contraceptives should only be provided in a manner consistent with Article 12 of the CRPD. Specifically, in such cases a process of supported decision-making should be instituted in which individuals who are trusted by the individual with disabilities, personal ombudsman and other support persons jointly participate with the individual in reaching a decision that is, to the greatest extent possible, consistent with the will and preference of that individual. Given the history of involuntary sterilization of persons with disabilities, often as a technique for menstrual management in institutions,11 it is especially important to ensure that decisions about sterilization are only made with the full, uncoerced and informed consent of the individual, either alone or with support.

2.5.2. Adolescents

Adolescents in many countries lack adequate access to contraceptive information and services that are necessary to protect their sexual and reproductive health. There is an urgent need to implement programmes that both meet the contraceptive needs of adolescents and remove barriers to services. In general, adolescents are eligible to use all the same methods of contraception as adults, and must have access to a variety of contraceptive choices. Age alone does not constitute a medical reason for denying any method to adolescents. While some concerns have been expressed about the use of certain contraceptive methods by adolescents (e.g. the use of progestogen-only injectables by those below 18 years), these concerns must be balanced against the advantages of preventing unintended pregnancy. It is clear that many of the same eligibility criteria that apply to older clients also apply to young people. However, some conditions (e.g. cardiovascular disorders) that may limit the use of some methods in older women do not generally affect young people, since these conditions are rare in this age group.

Political and cultural factors may affect adolescents' ability to access contraceptive information and services. For example, where contraceptive services are available, adolescents (in particular unmarried ones) may not be able to obtain them because of restrictive laws and policies. Even if adolescents are able to obtain contraceptive services, they may not do so because of fear that their confidentiality will not be respected, or that health workers may be judgmental. All adolescents, regardless of marital status, have a right to privacy and confidentiality in health matters, including reproductive health care. Appropriate sexual and reproductive health services, including contraception, should be available and accessible to all adolescents without necessarily requiring parental or guardian authorization by law, policy or practice.

Social and behavioural issues should be key considerations in the choice of contraceptive methods by adolescents. For example, in some settings, adolescents are also at increased risk for STIs, including HIV. While adolescents may choose to use any one of the contraceptive methods available in their communities, in some cases, using methods that do not require a daily regimen may be more convenient. Adolescents, married or unmarried, have also been shown to be less tolerant of side-effects and therefore have high discontinuation rates. Method choice may also be influenced by factors such as sporadic patterns of intercourse and the need to conceal sexual activity and contraceptive use. For instance, sexually active adolescents who are unmarried have very different needs from those who are married and want to postpone, space or limit pregnancy. Expanding the number of method choices offered can lead to improved satisfaction, increased acceptance and increased prevalence of contraceptive use. Proper education and counselling – both before and at the time of method selection – can help adolescents address their particular needs and make informed and voluntary decisions. Every effort should be made to prevent the costs of services and/or methods from limiting the options available.

2.6. Summary of changes within the MEC fifth edition

The following tables highlight changes within the fifth edition of the MEC, compared with the fourth edition (see Tables 2.4–2.6). These changes include: changes to MEC categories between the earlier editions and the fifth edition; recommendations for new conditions issued in the fifth edition; changes to the labelling of certain conditions (in order to be consistent with current clinical practice); and details for the new contraceptive methods included in this fifth edition.

Table 2.4. Summary of changes from the fourth edition to the fifth edition of the MEC (changes are highlighted in bold).

Table 2.4

Summary of changes from the fourth edition to the fifth edition of the MEC (changes are highlighted in bold).

Table 2.5. Emergency contraceptive pills (ECPs) (changes are highlighted in bold).

Table 2.5

Emergency contraceptive pills (ECPs) (changes are highlighted in bold). Emergency contraceptive pills (ECPs) (changes are highlighted in bold)

Table 2.6. Progesterone-releasing vaginal ring (PVR) (changes are highlighted in bold).

Table 2.6

Progesterone-releasing vaginal ring (PVR) (changes are highlighted in bold).

2.7. Tables

2.7.1. Combined hormonal contraceptives (CHCs)

COMBINED ORAL CONTRACEPTIVES (COCs)

The recommendations in this guidance refer to low-dose COCs containing ≤ 35 mcg ethinyl estradiol combined with a progestogen.

Venous thrombosis is rare among women of reproductive age. All COCs are associated with an increased risk for venous thromboembolism (VTE) compared to non-use. A number of studies have found differences in risk for VTE associated with COCs containing different types of progestogens (119). Current evidence suggests that COCs containing levonorgestrel, norethisterone and norgestimate are associated with the lowest risk (20). The absolute differences, however, are very small.

Limited data do not suggest that the small absolute risk for arterial events associated with COC use varies according to the type of progestogen (5, 6, 2034).

Recommendations in this guidance are the same for all COC formulations, irrespective of their progestogen content.

COMBINED INJECTABLE CONTRACEPTIVES (CICs)

Two CIC formulations, are considered here:

  1. Cyclofem = medroxyprogesterone acetate 25 mg plus estradiol cypionate 5 mg
  2. Mesigyna = norethisterone enanthate 50 mg plus estradiol valerate 5 mg

CICs contain the naturally occurring estrogen, estradiol plus a progestogen (3539). Estradiol is less potent, has a shorter duration of effect and is more rapidly metabolized than the synthetic estrogens used in other contraceptive formulations such as COCs, the combined contraceptive patch (P) and the combined contraceptive vaginal ring (CVR). These differences imply that the type and magnitude of estrogen-related side-effects associated with CICs may be different from those experienced by COC/P/CVR users. In fact, short-term studies of CICs have shown little effect on blood pressure, haemostasis and coagulation, lipid metabolism and liver function in comparison with COCs (4042). As CICs are administered by injection, the first-pass metabolism by the liver is avoided, thereby minimizing estradiol's effect on the liver.

However, CICs are a relatively new contraceptive method, and there are few epidemiological data on their long-term effects. There is also the concern that, while the effect of the hormonal exposure associated with use of COCs and progestogen-only pills (POPs) can be reduced immediately by discontinuing their use, this is not the case with injectables, for which the effect continues for some time after the last injection.

Pending further evidence, the Guideline Development Group (GDG) concluded that the evidence available for COCs applies to CICs in many but not all instances. Therefore, the GDG assigned categories for CICs somewhere between the categories for COCs and POPs. However, for severe pathologies (e.g. ischaemic heart disease), the classification of conditions was the same as for COCs. The assigned categories should, therefore, be considered a preliminary, best judgement, which will be re-evaluated as new data become available.

COMBINED CONTRACEPTIVE PATCH (P) AND COMBINED CONTRACEPTIVE VAGINAL RING (CVR)

The combined contraceptive patch (P) and combined vaginal ring (CVR) are relatively new contraceptive methods. Limited information is available on the safety of these methods among women with specific medical conditions. Moreover, epidemiological data on the long-term effects of P and CVR use were not available for the GDG to review. Most of the available studies received support from the manufacturers of these methods.

According to available evidence, the P provides a comparable safety and pharmacokinetic profile to COCs with similar hormone formulations (4360). Reports of transient, short-term breast discomfort and skin-site reactions were greater among P users; however, less than 25% of users experienced these events (45, 49, 50, 5658, 61). Limited evidence suggests the effectiveness of the P may decline for women weighing 90 kg or more (58, 60).

According to available evidence, the CVR provides a comparable safety and pharmacokinetic profile and has similar effects on ovarian function to COCs with similar hormone formulations in healthy women (6175). Evidence from use in obese women (BMI ≥ 30 kg/m2) found that weight gain for women in this category was not different between CVR users and COC users (76). Limited evidence from use in women post medical and surgical abortion found no serious adverse events and no infection related to use during three cycles of follow-up post-abortion (77), and limited evidence on women with low-grade squamous intraepithelial lesions found that use of the vaginal ring did not worsen the condition (64).

Pending further evidence, the GDG concluded that the evidence available for COCs applies to the combined contraceptive P and CVR, and therefore the P and CVR should have the same categories as COCs. The assigned categories should, therefore, be considered a preliminary, best judgement, which will be re-evaluated as new data become available.

COMBINED HORMONAL CONTRACEPTIVES (CHCs)
CHCs do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, the correct and consistent use of condoms is recommended. When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.
CONDITIONCATEGORY
I = initiation, C = continuation
CLARIFICATIONS/EVIDENCE
COCPCVRCIC
recommendations reviewed for the MEC 5th edition, further details after this table
* additional comments after this table
COC = combined oral contraceptive
P = combined contraceptive patch
CVR = combined contraceptive vaginal ring
CIC = combined injectable contraceptive
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY
PREGNANCYNANANANANA = not applicable

Clarification: Use of COCs, P, CVR or CICs is not required. There is no known harm to the woman, the course of her pregnancy, or the fetus if COCs, P, CVR or CICs are accidentally used during pregnancy.
AGE*Evidence: Evidence about whether CHC use affects fracture risk is inconsistent (7889), although 3 recent studies show no effect (9092). CHC use may decrease bone mineral density (BMD) in adolescents, especially in those choosing very low dose formulations (< 30 μg ethinyl estradiol-containing COCs) (91, 93105). CHC use has little to no effect on BMD in premenopausal women (90, 93102, 106109), and may preserve bone mass in those who are perimenopausal (103, 104, 110117). BMD is a surrogate marker for fracture risk that may not be valid for premenopausal women, and which, therefore, may not accurately predict current or future (postmenopausal) fracture risk (118120).
a) Menarche to < 40 years1111
b) ≥ 40 years2222
PARITY
a) Nulliparous1111
b) Parous1111
BREASTFEEDING Evidence: Clinical studies demonstrate conflicting results regarding effects on breastfeeding continuation or exclusivity in women exposed to COCs during lactation. No consistent effects on infant growth or illness have been reported (121126). Adverse health outcomes or manifestations of exogenous estrogen in infants exposed to combined contraceptives through breast-milk have not been demonstrated; however, studies have been inadequately designed to determine whether a risk of either serious or subtle long-term effects exists.
a) < 6 weeks postpartum4444
b) ≥ 6 weeks to < 6 months postpartum (primarily breastfeeding)3333
c) ≥ 6 months postpartum2222
POSTPARTUM (IN NON-BREASTFEEDING WOMEN)

Although the risk of venous thromboembolism (VTE) is the same in breastfeeding and non-breastfeeding women, use of CHCs is generally not recommended prior to 6 months postpartum in women who are breastfeeding.
a) < 21 daysClarification: For women up to 6 weeks postpartum with other risk factors for VTE, such as immobility, transfusion at delivery, BMI > 30 kg/m2, postpartum haemorrhage, immediately post-caesarean delivery, pre-eclampsia or smoking, use of CHCs may pose an additional increased risk for VTE.

Evidence: VTE risk is elevated during pregnancy and the postpartum period; this risk is most pronounced in the first 3 weeks after delivery, declining to near baseline levels by 42 days postpartum (127131). Use of CHCs, which increases the risk of VTE in healthy reproductive-age women, may pose an additional risk during this time (132). Risk of pregnancy during the first 21 days postpartum is very low, but increases after that time in non-breastfeeding women; ovulation before first menses is common (133).
 i) without other risk factors for VTE3333
 ii) with other risk factors for VTE4444
b) ≥ 21 days to 42 days
 i) without other risk factors for VTE2222
 ii) with other risk factors for VTE3333
c) > 42 days1111
POST-ABORTIONClarification: COCs, P, CVR or CICs may be started immediately post-abortion.

Evidence: Women who started taking COCs immediately after first-trimester medical or surgical abortion did not experience more side-effects or adverse vaginal bleeding outcomes or clinically significant changes in coagulation parameters compared with women who used a placebo, an IUD, a non-hormonal contraceptive method, or delayed COC initiation (134141). Limited evidence on women using the CVR immediately after first-trimester medical or surgical abortion indicated no serious adverse events and no infection related to CVR use during 3 cycles of follow-up post-abortion (77).
a) First trimester1111
b) Second trimester1111
c) Immediate post-septic abortion1111
PAST ECTOPIC PREGNANCY*1111
HISTORY OF PELVIC SURGERY1111
SMOKINGEvidence: COC users who smoked were at increased risk of cardiovascular diseases, especially myocardial infarction (MI), compared with those who did not smoke. Studies also showed an increased risk of MI with increasing number of cigarettes smoked per day (30, 31, 142151).
a) Age < 35 years2222
b) Age ≥ 35 years
 i) < 15 cigarettes/day3332
 ii) ≥ 15 cigarettes/day4443
OBESITYEvidence: Obese women who use COCs are more likely to experience VTE than obese women who do not use COCs. The absolute risk of VTE in healthy women of reproductive age is small. Limited evidence suggests that obese women who use COCs do not have a higher risk of acute MI or stroke than obese non-users (146, 147, 151156). Limited evidence suggests obese women are no more likely to gain weight after 3 cycles of using CVR or COCs than overweight or normal-weight women. A similar weight gain during 3 months was noted in both the COC group and the CVR group across all BMI categories (76). Overall, evidence suggests that contraceptive effectiveness is maintained among obese CHC users (157172); however, among women with very high BMI using COC, evidence is inconsistent (161, 167, 171). No association was found between pregnancy risk and BMI among P users (161, 167, 171). The effectiveness of the patch decreased among women who weighed > 90 kg in 1 study (172).
a) ≥ 30 kg/m2 BMI2222
b) Menarche to < 18 years and ≥ 30 kg/m2 BMI2222
BLOOD PRESSURE MEASUREMENT UNAVAILABLENANANANANA = not applicable

Clarification: It is desirable to have blood pressure measurements taken before initiation of COC, P, CVR or CIC use. However, in some settings, blood pressure measurements are unavailable. In many of these settings, pregnancy-related morbidity and mortality risks are high, and COCs, P, CVR or CICs may be among the few methods widely available. In such settings, women should not be denied use of COCs, P, CVR or CICs simply because their blood pressure cannot be measured.
CARDIOVASCULAR DISEASE
MULTIPLE RISK FACTORS FOR ARTERIAL CARDIOVASCULAR DISEASE
(e.g. older age, smoking, diabetes, hypertension and known dyslipidaemias)
3/43/43/43/4Clarification: When a woman has multiple major risk factors, any of which alone would substantially increase the risk of cardiovascular disease, use of COCs, P, CVR or CICs may increase her risk to an unacceptable level. However, a simple addition of categories for multiple risk factors is not intended; for example, a combination of 2 risk factors assigned a Category 2 may not necessarily warrant a higher category.
HYPERTENSION

For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, the risk of cardiovascular disease may increase substantially. A single reading of blood pressure level is not sufficient to classify a woman as hypertensive.
a) History of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy)3333Clarification: Evaluation of cause and level of hypertension is recommended, as soon as feasible.

Evidence: Women who did not have a blood pressure check before initiation of COC use had an increased risk of acute MI and stroke (26, 32, 33, 173, 174).
b) Adequately controlled hypertension, where blood pressure CAN be evaluated3333Clarification: Women adequately treated for hypertension are at reduced risk of acute MI and stroke as compared with untreated women. Although there are no data, COC, P, CVR or CIC users with adequately controlled and monitored hypertension should be at reduced risk of acute MI and stroke compared with untreated hypertensive COC, P, CVR or CIC users.

Evidence: Among women with hypertension, COC users were at increased risk of stroke, acute MI, and peripheral arterial disease compared with non-users (14, 26, 31, 33, 142, 144, 150, 151, 173185). Discontinuation of COCs in women with hypertension may improve blood pressure control (186).
c) Elevated blood pressure levels (properly taken measurements)
i) systolic 140–159 or diastolic 90–99 mm Hg3333
ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg4444
d) Vascular disease4444
HISTORY OF HIGH BLOOD PRESSURE DURING PREGNANCY
(where current blood pressure is measurable and normal)
2222Evidence: Women using COCs who had a history of high blood pressure in pregnancy had an increased risk of MI and VTE, compared with COC users who did not have a history of high blood pressure during pregnancy. The absolute risks of acute MI and VTE in this population remained small (32, 33, 151, 174, 176, 187192).
DEEP VEIN THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)*
a) History of DVT/PE4444
b) Acute DVT/PE4444
c) DVT/PE and established on anticoagulant therapy4444
d) Family history
(first-degree relatives)
2222
e) Major surgery
 i) with prolonged immobilization4444
 ii) without prolonged immobilization2222
f) Minor surgery without immobilization1111
KNOWN THROMBOGENIC MUTATIONS
(e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)
4444Clarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening.

Evidence: Among women with thrombogenic mutations, COC users had a 2- to 20-fold higher risk of thrombosis than non-users (3, 155, 193214).
SUPERFICIAL VENOUS DISORDERS
a) Varicose veins1111Evidence: One study suggested that among women with varicose veins, the rate of VTE and superficial venous thrombosis (SVT) was higher in oral contraceptive users compared with non-users; however, statistical significance was not reported and the number of events was small (215).
b) Superficial venous thrombosis (SVT)2222Clarification: SVT may be associated with an increased risk of VTE.

Evidence: One study demonstrated that among women with SVT, the risk of VTE was higher in oral contraceptive users compared with non-users (216).
CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE4444
STROKE
(history of cerebrovascular accident)
4444
KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORS 2222Clarification: Routine screening is not appropriate because of the rarity of the condition and the high cost of screening. Increased levels of total cholesterol, low-density lipoprotein (LDL) and triglycerides, as well as a decreased level of high-density lipoprotein (HDL), are known risk factors for cardiovascular disease. Women with known severe genetic lipid disorders are at much higher lifetime risk for cardiovascular disease and may warrant further clinical consideration.

Evidence: Limited evidence on use of CHCs among women with dyslipidaemia and risk of cardiovascular outcomes provided inconsistent results. One study suggested an increased risk for MI among COC users with hypercholesterolaemia compared to non-users without hypercholesterolaemia (217); 1 study suggested an increased risk for VTE and for stroke among COC users with dyslipidaemia compared to COC users without dyslipidaemia (22); and 1 study suggested no worsening of lipid abnormalities among CHC users with dyslipidaemia compared to non-users with dyslipidaemia (218). No evidence of risk for pancreatitis was identified.
VALVULAR HEART DISEASE*
a) Uncomplicated2222
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)4444
RHEUMATIC DISEASES
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

People with SLE are at increased risk of ischaemic heart disease, stroke and venous thromboembolism (VTE). Categories assigned to such conditions in the Medical eligibility criteria for contraceptive use should be the same for women with SLE who present with these conditions. For all categories of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors. Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives (219236).
a) Positive (or unknown) antiphospholipid antibodies4444Evidence: Antiphospholipid antibodies are associated with a higher risk for both arterial and venous thrombosis (237-239).
b) Severe thrombocytopenia2222
c) Immunosuppressive treatment2222
d) None of the above2222
NEUROLOGIC CONDITIONS
HEADACHES*ICICICICClarification: Classification depends on accurate diagnosis of those severe headaches that are migrainous and those that are not. Any new headaches or marked changes in headaches should be evaluated. Classification is for women without any other risk factors for stroke. Risk of stroke increases with age, hypertension and smoking.

Evidence: Among women with migraine, women who also had aura had a higher risk of stroke than those without aura (240242). Women with a history of migraine who use COCs are about 2–4 times as likely to have an ischaemic stroke as non-users with a history of migraine (142, 154, 181, 182, 240246).
a) Non-migrainous (mild or severe)12121212
b) Migraine
 i) without aura
  age < 35 years23232323
  age ≥ 35 years34343434
 ii) with aura, at any age44444444
EPILEPSY1111Clarification: If a woman is taking anticonvulsants, refer to the last section of this table, on drug interactions. Certain anticonvulsants lower COC effectiveness. The extent to which P, CVR or CIC use is similar to COC use in this regard remains unclear.
DEPRESSIVE DISORDERS
DEPRESSIVE DISORDERS1111Clarification: The classification is based on data for women with selected depressive disorders. No data on bipolar disorder or postpartum depression were available. There is a potential for drug interactions between certain antidepressant medications and hormonal contraceptives.

Evidence: COC use did not increase depressive symptoms in women with depression compared to baseline or to non-users with depression (247256).
REPRODUCTIVE TRACT INFECTIONS AND DISORDERS
VAGINAL BLEEDING PATTERNS*
a) Irregular pattern without heavy bleeding1111
b) Heavy or prolonged bleeding (includes regular and irregular patterns)1111Clarification: Unusually heavy bleeding should raise the suspicion of a serious underlying condition.

Evidence: A Cochrane Collaboration review identified 1 randomized controlled trial evaluating the effectiveness of COC use compared with naproxen and danazol in treating menorrhagic women. Women with menorrhagia did not report worsening of the condition or any adverse events related to COC use (257).
UNEXPLAINED VAGINAL BLEEDING*
(suspicious for serious condition)
a) Before evaluation2222Clarification: If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation.
ENDOMETRIOSIS1111Evidence: A Cochrane review identified 1 randomized controlled trial evaluating the effectiveness of COC use compared with a gonadotropin-releasing hormone (GnRH) analogue in treating the symptoms of endometriosis. Women with endometriosis did not report worsening of the condition or any adverse events related to COC use (258).
BENIGN OVARIAN TUMOURS (INCLUDING CYSTS)1111
SEVERE DYSMENORRHOEA1111Evidence: There was no increased risk of side-effects with COC use among women with dysmenorrhoea compared with women not using COCs. Some COC users had a reduction in pain and bleeding (259, 260).
GESTATIONAL TROPHOBLASTIC DISEASEEvidence: Following molar pregnancy evacuation, the balance of evidence found COC use did not increase the risk of post-molar trophoblastic disease, and some COC users experienced a more rapid regression in human chorionic gonadotropin (hCG) levels, compared with non-users (261268). Limited evidence suggests that use of COCs during chemotherapeutic treatment does not significantly affect the regression or treatment of post-molar trophoblastic disease compared with women who used a non-hormonal contraceptive method or depot medroxyprogesterone acetate (DMPA) during chemotherapeutic treatment (269).
a) Decreasing or undetectable β-hCG levels1111
b) Persistently elevated β-hCG levels or malignant disease1111
CERVICAL ECTROPION*1111
CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)2222Evidence: Among women with persistent human papillomavirus (HPV) infection, long-term COC use (≥ 5 years) may increase the risk of carcinoma in situ and invasive carcinoma (64, 270). Limited evidence on women with low-grade squamous intraepithelial lesions found use of the vaginal ring did not worsen the condition (64).
CERVICAL CANCER* (AWAITING TREATMENT)2222
BREAST DISEASE*
a) Undiagnosed mass2222Clarification: Evaluation should be pursued as early as possible.
b) Benign breast disease1111
c) Family history of cancer1111Evidence: Women with breast cancer susceptibility genes (such as BRCA1 and BRCA2) have a higher baseline risk of breast cancer than women without these genes. The baseline risk of breast cancer is also higher among women with a family history of breast cancer than among those who do not have such a history. Current evidence, however, does not suggest that the increased risk of breast cancer among women with either a family history of breast cancer or breast cancer susceptibility genes is modified by the use of combined oral contraceptives (175, 271293).
d) Breast cancer
 i) current4444
 ii) past and no evidence of current disease for 5 years3333
ENDOMETRIAL CANCER*1111
OVARIAN CANCER*1111
UTERINE FIBROIDS*
a) Without distortion of the uterine cavity1111
b) With distortion of the uterine cavity1111
PELVIC INFLAMMATORY DISEASE (PID)*
a) Past PID (assuming no current risk factors for STIs)
 i) with subsequent pregnancy1111
 ii) without subsequent pregnancy1111
b) PID – current1111
STIs
a) Current purulent cervicitis or chlamydial infection or gonorrhoea1111
b) Other STIs (excluding HIV and hepatitis)1111
c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)1111
d) Increased risk of STIs1111Evidence: Evidence suggests that there may be an increased risk of chlamydial cervicitis among COC users at high risk of STIs. For other STIs, there is either evidence of no association between COC use and STI acquisition or too limited evidence to draw any conclusions (289369).
HIV/AIDS
High risk of HIV1111Evidence: Eight studies assessed the use of COCs and were considered to be “informative but with important limitations” (370). Seven of these studies found no statistically significant association between use of COCs and HIV acquisition (371378), although 1 study among sex workers in Kenya did (379).
Asymptomatic or mild HIV clinical disease (WHO stage 1 or 2)1111Clarification for asymptomatic or mild HIV disease (WHO stage 1 or 2) and severe or advanced HIV disease (WHO stage 3 or 4): Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to the last section of this table, on drug interactions.

Evidence for asymptomatic or mild HIV disease (WHO stage 1 or 2) and severe or advanced HIV disease (WHO stage 3 or 4): Out of 8 available studies, 7 suggested no association between use of COCs and progression of HIV, as measured by CD4 count < 200 cells/mm3, initiation of antiretroviral therapy (ART), or mortality (380386). One randomized controlled trial found an increased risk of a composite outcome of declining CD4 count or death among COC users when compared with users of copper-bearing IUDs (387, 388). Two prospective observational studies directly assessed the effects of different hormonal contraceptive methods on female-to-male HIV transmission by measuring seroconversions in male partners of women known to be using hormonal contraceptives. One of these studies reported an elevated, but not statistically significant, point estimate for COCs (378). The other study also did not find a statistically significant association for COCs (389). Studies indirectly assessing the effect of various hormonal contraceptive methods on female-to-male HIV transmission by measuring genital viral shedding as a proxy for infectivity have had mixed results. The majority of indirect studies measuring whether various hormonal contraceptive methods affect plasma HIV viral load have found no effect (381, 390404).
Severe or advanced HIV clinical disease (WHO stage 3 or 4)1111
OTHER INFECTIONS
SCHISTOSOMIASIS
a) Uncomplicated1111Evidence: Among women with uncomplicated schistosomiasis, COC use had no adverse effects on liver function (405411).
b) Fibrosis of the liver
(if severe, see cirrhosis)
1111
TUBERCULOSIS
a) Non-pelvic1111Clarification: If a woman is taking rifampicin, refer to the last section of this table, on drug interactions. Rifampicin is likely to decrease COC effectiveness. The extent to which P or CVR use is similar to COC use in this regard remains unclear.
b) Pelvic1111
MALARIA1111
ENDOCRINE CONDITIONS
DIABETES
a) History of gestational disease1111Evidence: The development of non-insulin-dependent diabetes in women with a history of gestational diabetes is not increased by the use of COCs (412419). Likewise, lipid levels appear to be unaffected by COC use (420422).
b) Non-vascular diseaseEvidence: Among women with insulin- or non-insulin-dependent diabetes, COC use had limited effect on daily insulin requirements and no effect on long-term diabetes control (e.g. haemoglobin A1c levels) or progression to retinopathy. Changes in lipid profile and haemostatic markers were limited, and most changes remained within normal values (419, 422430).
 i) non-insulin dependent2222
 ii) insulin dependent2222
c) Nephropathy/retinopathy/neuropathy3/43/43/43/4Clarification: The category should be assessed according to the severity of the condition.
d) Other vascular disease or diabetes of > 20 years' duration3/43/43/43/4Clarification: The category should be assessed according to the severity of the condition.
THYROID DISORDERS
a) Simple goitre1111
b) Hyperthyroid1111
c) Hypothyroid1111
GASTROINTESTINAL CONDITIONS
GALL BLADDER DISEASE*
a) Symptomatic
 i) treated by cholecystectomy2222
 ii) medically treated3332
 iii) current3332
b) Asymptomatic2222
HISTORY OF CHOLESTASIS*
a) Pregnancy related2222
b) Past-COC related3332
VIRAL HEPATITISICICICIC
a) Acute or flare3/423/423/4232Clarification: The category should be assessed according to the severity of the condition.
b) Carrier11111111Evidence: Data suggest that in women with chronic hepatitis, COC use does not increase the rate or severity of cirrhotic fibrosis, nor does it increase the risk of hepatocellular carcinoma (431, 432). For women who are carriers, COC use does not appear to trigger liver failure or severe dysfunction (408, 433, 434). Evidence is limited for COC use during active hepatitis (435, 436).
c) Chronic11111111
CIRRHOSIS
a) Mild (compensated)1111
b) Severe (decompensated)4443
LIVER TUMOURS*
a) Benign
i) focal nodular hyperplasia2222Evidence: There is limited, direct evidence that hormonal contraceptive use does not influence either progression or regression of liver lesions among women with focal nodular hyperplasia (437439).
ii) hepatocellular adenoma4443
b) Malignant (hepatoma)4443/4
ANAEMIAS
THALASSAEMIA*1111
SICKLE CELL DISEASE2222
IRON-DEFICIENCY ANAEMIA*1111
DRUG INTERACTIONS
ANTIRETROVIRAL THERAPY (ART)
a) Nucleoside reverse transcriptase inhibitors (NRTIs)Evidence: NRTIs do not appear to have significant risk of interactions with hormonal contraceptive methods (440, 441).
 Abacavir (ABC)1111
 Tenofovir (TDF)1111
 Zidovudine (AZT)1111
 Lamivudine (3TC)1111
 Didanosine (DDI)1111
 Emtricitabine (FTC)1111
 Stavudine (D4T)1111
b) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)Clarification: Antiretroviral drugs have the potential to either decrease or increase the levels of steroid hormones in women using hormonal contraceptives. Pharmacokinetic data suggest potential drug interactions between some antiretroviral drugs (particularly some NNRTIs and ritonavir-boosted PIs) and some hormonal contraceptives. These interactions may reduce the effectiveness of the hormonal contraceptive.

Evidence: Three clinical studies, including 1 large study, found use of nevirapine-containing ART did not increase ovulation or pregnancy rates in women taking COCs (442445). For efavirenz-containing ART, a pharmacokinetic study showed consistent significant decreases in contraceptive hormone levels in women taking COCs, and a small clinical study showed higher ovulation rates in women taking efavirenz-containing ART and COCs (445447). Etravirine and rilpivirine do not interact with COCs (448, 449).
 Efavirenz (EFV)2222
 Etravirine (ETR)1111
 Nevirapine (NVP)2222
 Rilpivirine (RPV)1111
c) Protease inhibitors (PIs)
 Ritonavir-boosted atazanavir (ATV/r)2222
 Ritonavir-boosted lopinavir (LPV/r)2222
 Ritonavir-boosted darunavir (DRV/r)2222
 Ritonavir (RTV)2222
d) Integrase inhibitorsEvidence: The integrase inhibitor raltegravir does not appear to interact with COCs (440, 441, 454, 455).
 Raltegravir (RAL)1111
ANTICONVULSANT THERAPY
a) Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)3332Clarification: Although the interaction of certain anticonvulsants with COCs, P or CVR is not harmful to women, it is likely to reduce the effectiveness of COCs, P or CVR. Use of other contraceptives should be encouraged for women who are long-term users of any of these drugs. When a COC is chosen, a preparation containing a minimum of 30 μg of ethinyl estradiol (EE) should be used.

Evidence: Use of certain anticonvulsants may decrease the effectiveness of COCs (456-459).
b) Lamotrigine3333Clarification: The recommendation for lamotrigine does not apply when lamotrigine is already being taken with other drugs that strongly inhibit (such as sodium valproate) or induce (such as carbamazepine) its metabolism, since, in these cases, the moderate effect of the combined contraceptive is unlikely to be apparent.

Evidence: Pharmacokinetic studies show levels of lamotrigine decrease significantly during COC use and increase significantly during the pill-free interval (460-464). Some women who used both COCs and lamotrigine experienced increased seizure activity in 1 trial (464).
ANTIMICROBIAL THERAPY
a) Broad-spectrum antibiotics1111Evidence: Most broad-spectrum antibiotics do not affect the contraceptive effectiveness of COCs (465501), P (502), or CVR (503).
b) Antifungals1111Evidence: Studies of antifungal agents have shown no clinically significant pharmacokinetic interactions with COCs (504513) or CVR (514).
c) Antiparasitics1111Evidence: Studies of antiparasitic agents have shown no clinically significant pharmacokinetic interactions with COCs (411, 515519).
d) Rifampicin or rifabutin therapy3332Clarification: Although the interaction of rifampicin or rifabutin therapy with COCs, P, CVR or CICs is not harmful to women, it is likely to reduce the effectiveness of COCs, P, CVR or CICs. Use of other contraceptives should be encouraged for women who are long-term users of either of these drugs. When a COC is chosen, a preparation containing a minimum of 30 μg EE should be used.

Evidence: The balance of the evidence suggests that rifampicin reduces the effectiveness of COCs (520535). Data on rifabutin are limited, but effects on metabolism of COCs are less than with rifampicin, and small studies have not shown evidence of ovulation (363, 522, 535).

RECOMMENDATIONS REVIEWED FOR FIFTH EDITION

These recommendations were reviewed according to WHO requirements for guideline development, as part of the preparation of the Medical eligibility criteria for contraceptive use, fifth edition. The Population, Intervention, Comparator, Outcome (PICO) questions developed by the Guideline Development Group (GDG) and the databases searched to retrieve the evidence, which guided the preparation of systematic reviews, are described in greater detail in Part I of this document. Additionally, GRADE evidence profiles, the overall GRADE assessment of the quality of the evidence, summaries of the evidence supporting the recommendation(s), and other supplementary remarks from the GDG regarding the recommendations, are available in Part I.

ADDITONAL COMMENTS

AGE

Age ≥ 40 years: The risk of cardiovascular disease increases with age and may also increase with combined hormonal contraceptive (CHC) use. In the absence of other adverse clinical conditions, CHCs can be used until menopause.

PAST ECTOPIC PREGNANCY

The risk of future ectopic pregnancy is increased in these women. CHCs provide protection against pregnancy in general, including ectopic gestation.

DEEP VEIN THROMBOSIS/PULMONARY EMBOLISM

Family history of DVT/PE (first-degree relatives): Some conditions which increase the risk of DVT/PE are heritable.

VALVULAR HEART DISEASE

Among women with valvular heart disease, CHC use may further increase the risk of arterial thrombosis; women with complicated valvular heart disease are at greatest risk.

HEADACHES

Aura is a specific focal neurologic symptom. For more information on this and other diagnostic criteria, see: Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edition. Cephalalgia. 2004;24(Suppl 1):1–150.12

VAGINAL BLEEDING PATTERNS

Irregular menstrual bleeding patterns are common among healthy women.

UNEXPLAINED VAGINAL BLEEDING

There are no conditions that cause vaginal bleeding that will be worsened in the short term by use of CHCs.

CERVICAL ECTROPION

Cervical ectropion is not a risk factor for cervical cancer, and there is no need for restriction of CHC use.

CERVICAL CANCER (AWAITING TREATMENT)

There is some theoretical concern that CHC use may affect prognosis of the existing disease. While awaiting treatment, women may use CHCs. In general, treatment of this condition renders a woman sterile.

BREAST DISEASE

Breast cancer: Breast cancer is a hormonally sensitive tumour, and the prognosis of women with current or recent breast cancer may worsen with CHC use.

ENDOMETRIAL CANCER

COC use reduces the risk of developing endometrial cancer.

Awaiting treatment: Women may use COCs, CICs, P or CVR. In general, treatment of this condition renders a woman sterile.

OVARIAN CANCER

COC use reduces the risk of developing ovarian cancer.

Awaiting treatment: Women may use COCs, CICs, P or CVR. In general, treatment of this condition renders a woman sterile.

UTERINE FIBROIDS

COCs do not appear to cause growth of uterine fibroids, and CICs, P and CVR are not expected to either.

PELVIC INFLAMMATORY DISEASE (PID)

COCs may reduce the risk of PID among women with STIs, but do not protect against HIV or lower genital tract STIs. Whether CICs, P or CVR reduce the risk of PID among women with STIs is unknown but they do not protect against HIV or lower genital tract STIs.

GALL BLADDER DISEASE

COCs, CICs, P or CVR may cause a small increased risk of gall bladder disease.

There is also concern that COCs, CICs, P or CVR may worsen existing gall bladder disease.

Unlike COCs, CICs have been shown to have minimal effect on liver function in healthy women, and have no first-pass effect on the liver.

HISTORY OF CHOLESTASIS

Pregnancy-related: History of pregnancy-related cholestasis may predict an increased risk of developing COC-related cholestasis.

Past-COC-related: History of COC-related cholestasis predicts an increased risk with subsequent COC use.

LIVER TUMOURS

There is no evidence regarding hormonal contraceptive use among women with hepatocellular adenoma.

COC use in healthy women is associated with development and growth of hepatocellular adenoma.

THALASSAEMIA

There is anecdotal evidence from countries where thalassaemia is prevalent that COC use does not worsen the condition.

IRON-DEFICIENCY ANAEMIA

CHC use may decrease menstrual blood loss.

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495.
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496.
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497.
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498.
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499.
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501.
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505.
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2.7.2. Progestogen-only contraceptives (POCs)

PROGESTOGEN-ONLY PILLS (POPs)

POPs contain only a progestogen and no estrogen.

PROGESTOGEN-ONLY INJECTABLES (POIs)

These injectables include depot medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN).

There are three formulations considered here:

  1. DMPA-IM = 150 mg of DMPA given intramuscularly
  2. DMPA-SC = 104 mg of DMPA given subcutaneously
  3. NET-EN = 200 mg of NET-EN given intramuscularly

Identified evidence for the conditions of age, obesity, endometriosis and HIV among DMPA-SC users appear consistent with existing recommendations for DMPA-IM (112). Further, DMPA-SC and DMPA-IM appear to be therapeutically equivalent, with similar safety profiles when used by healthy women (3, 5, 11). Pending further evidence, the Guideline Development Group (GDG) concluded that the evidence available for DMPA-IM applies to DMPA-SC and, therefore, DMPA-SC should have the same categories as DMPA-IM; the assigned recommendations should be considered a preliminary best judgement, which will be re-evaluated as new data become available.

PROGESTOGEN-ONLY IMPLANTS

Progestogen-only implants are a type of long-acting, reversible contraception. The various types of implants that are considered here are the following:

  1. Levonorgestrel (LNG): The LNG-containing implants are Norplant®, Jadelle® and Sino-implant (II)®.
    1. Norplant® is a 6-rod implant, each rod containing 36 mg of LNG (no longer in production).
    2. Jadelle® is a 2-rod implant, each rod containing 75 mg of LNG
    3. Sino-implant (II) ® is a 2-rod implant, each rod containing 75 mg of LNG
  2. Etonogestrel (ETG): The ETG-containing implants are Implanon® and Nexplanon®. Both consist of a single-rod implant containing 68 mg of ETG.

No studies were identified that provided direct evidence on the use of the Sino-implant (II) among women with medical conditions in the MEC and included a comparison group. Evidence from three studies of healthy women demonstrate that Sino-implant (II) has a similar safety and pharmacokinetic profile to that of other LNG implants, with no significant differences in serious adverse events, such as ectopic pregnancy or discontinuation due to medical problems (1315). Therefore, safety data from studies of other LNG implants among women with medical conditions were used due to the similarity of Sino-implant (II) and other LNG implants in hormone formulation, quality profile and daily release rates. The GDG assigned the same recommendations for Sino-implant (II) as for the other LNG implants.

PROGESTOGEN-ONLY CONTRACEPTIVES (POCs)
POCs do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, the correct and consistent use of condoms is recommended. When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.
CONDITIONCATEGORY
I = initiation, C = continuation
CLARIFICATIONS/EVIDENCE
POPDMPA/NET-ENLNG/ETG
recommendations reviewed for the MEC 5th edition, further details after this table

* additional comments after this table
POP = progestogen-only pill
LNG/ETG = levonorgestrel and etonogestrel (implants)
DMPA = depot medroxyprogesterone acetate (injectable)
NET-EN = norethisterone enanthate (injectable)
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY
PREGNANCYNANANANA = not applicable

Clarification: Use of POCs is not required. There is no known harm to the woman, the course of her pregnancy, or the fetus if POCs are accidentally used during pregnancy. However, the relationship between DMPA use during pregnancy and its effects on the fetus remains unclear.
AGEEvidence: Most studies have found that women lose bone mineral density (BMD) during DMPA use, but recover BMD after discontinuation. Limited evidence shows a weak association with fracture, although 1 large study suggests that women who choose DMPA may be at higher risk for fracture even prior to initiation of the method (16). It is unclear whether adult women with long durations of DMPA use can regain BMD to baseline levels before entering menopause and whether adolescents can reach peak bone mass after discontinuation of DMPA. The relationship between these changes in BMD during the reproductive years and future fracture risk is unknown. Studies generally find no effect of POCs other than DMPA on BMD (5, 12, 1660).
a) Menarche to < 18 years121
b) 18 to 45 years111
c) > 45 years121
PARITY
a) Nulliparous111
b) Parous111
BREASTFEEDING Clarification: There is theoretical concern about the potential exposure of the neonate to DMPA/NET-EN during the first 6 weeks postpartum. In many settings, however, pregnancy-related morbidity and mortality risks are high, and access to services is limited. In such settings, DMPA/NET-EN may be among the few methods widely available and accessible to breastfeeding women immediately postpartum.

Evidence: Direct evidence demonstrates no harmful effect of POCs on breastfeeding performance (61109) and generally demonstrates no harmful effects on infant growth, health or development (74, 76, 89, 99); however, these studies have been inadequately designed to determine whether a risk of long-term effects exists. Animal data suggest an effect of progesterone on the developing brain; whether similar effects occur following progestogen exposure in humans is unclear (110112).
a) < 6 weeks postpartum232
b) ≥ 6 weeks to < 6 months postpartum (primarily breastfeeding)111
c) ≥ 6 months postpartum111
POSTPARTUM (NON-BREASTFEEDING WOMEN)
a) < 21 days111
b) ≥ 21 days111
POST-ABORTIONClarification: POCs may be started immediately post-abortion.

Evidence: Limited evidence suggests that there are no adverse side-effects when an LNG implant or NET-EN are initiated after first-trimester abortion (113116).
a) First trimester111
b) Second trimester111
c) Immediate post-septic abortion111
PAST ECTOPIC PREGNANCY*211
HISTORY OF PELVIC SURGERY111
SMOKING
a) Age < 35 years111
b) Age ≥ 35 years
 i) < 15 cigarettes/day111
 ii) ≥ 15 cigarettes/day111
OBESITYClarification: There is evidence for differential weight gain among normal-weight and obese adolescents who use DMPA, but not among those using NET-EN. However, NET-EN is Category 2 due to evidence regarding potential effects of NET-EN on BMD among adolescents (see row: Age).
Evidence: Among adult women, there is generally no association between baseline weight and weight gain among DMPA users compared with non-users. Evidence is mixed for adolescent DMPA users, with some studies observing greater weight gain among obese compared with normal-weight users, but other studies showing no association. Methodological differences across studies may account for the differences in findings. Data on other POC methods and other adverse outcomes are limited (10, 117133).
a) ≥ 30 kg/m2 BMI111
b) Menarche to < 18 years and ≥ 30 kg/m2 BMI121
BLOOD PRESSURE MEASUREMENT UNAVAILABLENANANANA = not applicable

Clarification: It is desirable to have blood pressure measurements taken before initiation of POC use. However, in some settings blood pressure measurements are unavailable. In many of these settings, pregnancy-related morbidity and mortality risks are high, and POCs are among the few methods widely available. In such settings, women should not be denied use of POCs simply because their blood pressure cannot be measured.
CARDIOVASCULAR DISEASE
MULTIPLE RISK FACTORS FOR ARTERIAL CARDIOVASCULAR DISEASE
(such as older age, smoking, diabetes, hypertension and known dyslipidaemias)
232Clarification: When multiple major risk factors exist, the risk of cardiovascular disease may increase substantially. Some POCs may increase the risk of thrombosis, although this increase is substantially less than with combined oral contraceptives (COCs). The effects of DMPA and NET-EN may persist for some time after discontinuation.
HYPERTENSION*

For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, the risk of cardiovascular disease may increase substantially. A single reading of blood pressure level is not sufficient to classify a woman as hypertensive.
a) History of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy)222Clarification: It is desirable to have blood pressure measurements taken before initiation of POC use. However, in some settings blood pressure measurements are unavailable. In many of these settings, pregnancy-related morbidity and mortality risks are high, and POCs are among the few types of methods widely available. In such settings, women should not be denied the use of POCs simply because their blood pressure cannot be measured.
b) Adequately controlled hypertension, where blood pressure CAN be evaluated121Clarification: Women adequately treated for hypertension are at reduced risk of acute myocardial infarction (MI) and stroke as compared with untreated women. Although there are no data, POC users with adequately controlled and monitored hypertension should be at reduced risk of acute MI and stroke compared with untreated hypertensive POC users.
c) Elevated blood pressure levels (properly taken measurements)Evidence: Limited evidence suggests that among women with hypertension, those who used POPs or progestogen-only injectables (POIs) had a small increased risk of cardiovascular events compared with women who did not use these methods (134).
 i) systolic 140–159 or diastolic 90–99 mm Hg121
 ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg232
d) Vascular disease232
HISTORY OF HIGH BLOOD PRESSURE DURING PREGNANCY
(where current blood pressure is measurable and normal)
111
DEEP VEIN THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)*
a) History of DVT/PE222
b) Acute DVT/PE333Evidence: There is no direct evidence on the use of POCs among women with DVT/PE on anticoagulant therapy. Although evidence on the risk of venous thrombosis with the use of POCs is inconsistent in otherwise healthy women, any small increased risk is substantially less than that with COCs (134136).
c) DVT/PE and established on anticoagulant therapy222Evidence: There is no direct evidence on the use of POCs among women with DVT/PE on anticoagulant therapy. Although evidence on the risk of venous thrombosis with the use of POCs is inconsistent in otherwise healthy women, any small increased risk is substantially less than that with COCs (134136). Limited evidence indicates that intramuscular injections of DMPA in women on chronic anticoagulation therapy does not pose a significant risk of haematoma at the injection site or increase the risk of heavy or irregular vaginal bleeding (137, 138).
d) Family history (first-degree relatives)111
e) Major surgery
 i) with prolonged immobilization222
 ii) without prolonged immobilization111
f) Minor surgery without immobilization111
KNOWN THROMBOGENIC MUTATIONS (e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)222Clarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening.
SUPERFICIAL VENOUS DISORDERS
a) Varicose veins111
b) Superficial venous thrombosis111
CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE*ICIC
23323
STROKE* (HISTORY OF CEREBROVASCULAR ACCIDENT)ICIC
23323
KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORS222Clarification: Routine screening is not appropriate because of the rarity of the condition and the high cost of screening.
VALVULAR HEART DISEASE
a) Uncomplicated111
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)111
RHEUMATIC DISEASES
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)*
People with SLE are at increased risk of ischaemic heart disease, stroke and venous thromboembolism. Categories assigned to such conditions in the Medical eligibility criteria for contraceptive use should be the same for women with SLE who present with these conditions. For all categories of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors. Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives (139156).
IC
a) Positive (or unknown) antiphospholipid antibodies3333Evidence: Antiphospholipid antibodies are associated with a higher risk for both arterial and venous thrombosis (157159).
b) Severe thrombocytopenia2322
c) Immunosuppressive treatment2222
d) None of the above2222
NEUROLOGIC CONDITIONS
HEADACHES*ICICIC
a) Non-migrainous (mild or severe)111111Clarification: Classification depends on accurate diagnosis of those severe headaches that are migrainous and those that are not. Any new headaches or marked changes in headaches should be evaluated. Classification is for women without any other risk factors for stroke. Risk of stroke increases with age, hypertension and smoking.
b) Migraine
 i) without aura
  age < 35 years122222
  age ≥ 35 years122222
 ii) with aura, at any age232323
EPILEPSY111Clarification: If a woman is taking anticonvulsants, refer to the last section of this table, on drug interactions. Certain anticonvulsants lower POC effectiveness.
DEPRESSIVE DISORDERS
DEPRESSIVE DISORDERS111Clarification: The classification is based on data for women with selected depressive disorders. No data on bipolar disorder or postpartum depression were available. There is a potential for drug interactions between certain antidepressant medications and hormonal contraceptives.

Evidence: POC use did not increase depressive symptoms in women with depression compared with baseline (160163).
REPRODUCTIVE TRACT INFECTIONS AND DISORDERS
VAGINAL BLEEDING PATTERNS*
a) Irregular pattern without heavy bleeding222
b) Heavy or prolonged bleeding (includes regular and irregular patterns)222Clarification: Unusually heavy bleeding should raise the suspicion of a serious underlying condition.
UNEXPLAINED VAGINAL BLEEDING*
(suspicious for serious condition)
Clarification: If pregnancy or an underlying pathological condition (such as pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation.
Before evaluation233
ENDOMETRIOSIS111
BENIGN OVARIAN TUMOURS
(including cysts)
111
SEVERE DYSMENORRHOEA111
GESTATIONAL TROPHOBLASTIC DISEASE
a) Decreasing or undetectable β-hCG levels111
b) Persistently elevated β-hCG levels or malignant disease111
CERVICAL ECTROPION111
CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)122Evidence: Among women with persistent human papillomavirus (HPV) infection, long-term DMPA use (≥ 5 years) may increase the risk of carcinoma in situ and invasive carcinoma (164).
CERVICAL CANCER*
(awaiting treatment)
122
BREAST DISEASE*
a) Undiagnosed mass222Clarification: Evaluation should be pursued as early as possible.
b) Benign breast disease111
c) Family history of cancer111
d) Breast cancer
 i) current444
 ii) past and no evidence of current disease for 5 years333
ENDOMETRIAL CANCER*111
OVARIAN CANCER*111
UTERINE FIBROIDS*
a) Without distortion of the uterine cavity111
b) With distortion of the uterine cavity111
PELVIC INFLAMMATORY DISEASE (PID)*
a) Past PID (assuming no current risk factors for STIs)
 i) with subsequent pregnancy111
 ii) without subsequent pregnancy111
b) PID – current111
STIs
a) Current purulent cervicitis or chlamydial infection or gonorrhoea111
b) Other STIs (excluding HIV and hepatitis)111
c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)111
d) Increased risk of STIs111Evidence: Evidence suggests that there may be an increased risk of chlamydial cervicitis among DMPA users at high risk of STIs. For other STIs, there is either evidence of no association between DMPA use and STI acquisition or too limited evidence to draw any conclusions. There is no evidence for other POCs (165172).
HIV/AIDS
HIGH RISK OF HIV111Clarification for asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) and severe or advanced HIV clinical disease (WHO stage 3 or 4): Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to the last section of this table, on drug interactions.

Evidence for asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) and severe or advanced HIV clinical disease (WHO stage 3 or 4): Out of 6 available studies, 5 suggest no association between use of POIs and progression of HIV, as measured by CD4 count < 200 cells/mm3, initiation of antiretroviral therapy (ART), or mortality (186190). One randomized trial found an increased risk of a composite outcome of declining CD4 count or death among oral contraceptive users (COCs and POPs) when compared with users of copper-bearing IUDs; this study, however, had significant loss to follow-up and method switching among groups, limiting its interpretation (188, 191). One study found no difference in ART initiation or CD4 count between users and non-users of the LNG-IUD (192). Two prospective observational studies directly assessed the effects of different hormonal contraceptive methods on female-to-male HIV transmission by measuring seroconversions in male partners of women living with HIV and known to be using hormonal contraceptives. One study reported a statistically significant association between use of POIs and female-to-male transmission of HIV (180), while another study did not find a statistically significant association between use of DMPA and female-to-male HIV transmission (184). The findings of studies indirectly assessing the effects of various hormonal contraceptive methods on female-to-male HIV transmission by measuring genital viral shedding as a proxy for infectivity have been mixed. Most of indirect studies measuring whether various hormonal contraceptive methods affect plasma HIV viral load have found no effect (189, 193207).
ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE
(WHO STAGE 1 OR 2)
111Clarification for asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) and severe or advanced HIV clinical disease (WHO stage 3 or 4): Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to the last section of this table, on drug interactions.

Evidence for asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) and severe or advanced HIV clinical disease (WHO stage 3 or 4): Out of 6 available studies, 5 suggest no association between use of POIs and progression of HIV, as measured by CD4 count < 200 cells/mm3, initiation of antiretroviral therapy (ART), or mortality (186190). One randomized trial found an increased risk of a composite outcome of declining CD4 count or death among oral contraceptive users (COCs and POPs) when compared with users of copper-bearing IUDs; this study, however, had significant loss to follow-up and method switching among groups, limiting its interpretation (188, 191). One study found no difference in ART initiation or CD4 count between users and non-users of the LNG-IUD (192). Two prospective observational studies directly assessed the effects of different hormonal contraceptive methods on female-to-male HIV transmission by measuring seroconversions in male partners of women living with HIV and known to be using hormonal contraceptives. One study reported a statistically significant association between use of POIs and female-to-male transmission of HIV (180), while another study did not find a statistically significant association between use of DMPA and female-to-male HIV transmission (184). The findings of studies indirectly assessing the effects of various hormonal contraceptive methods on female-to-male HIV transmission by measuring genital viral shedding as a proxy for infectivity have been mixed. Most of indirect studies measuring whether various hormonal contraceptive methods affect plasma HIV viral load have found no effect (189, 193207).
SEVERE OR ADVANCED HIV CLINICAL DISEASE
(WHO STAGE 3 OR 4)
111
OTHER INFECTIONS
SCHISTOSOMIASIS
a) Uncomplicated111Evidence: Among women with uncomplicated schistosomiasis, limited evidence showed that DMPA use had no adverse effects on liver function (208).
b) Fibrosis of the liver (if severe, see cirrhosis)111
TUBERCULOSIS
a) Non-pelvic111Clarification: If a woman is taking rifampicin, refer to the last section of this table, on drug interactions. Rifampicin is likely to decrease the effectiveness of some POCs.
b) Pelvic111
MALARIA111
ENDOCRINE CONDITIONS
DIABETES*
a) History of gestational disease111Evidence: POCs had no adverse effects on serum lipid levels in women with a history of gestational diabetes in 2 small studies (209, 210). There is only limited and inconsistent evidence regarding the development of non-insulin-dependent diabetes among users of POCs with a history of gestational diabetes (211214).
b) Non-vascular diseaseEvidence: Among women with insulin- or non-insulin-dependent diabetes, limited evidence on the use of progestogen-only methods (POPs, DMPA injectable, LNG implant) suggests that these methods have little effect on short-term or long-term diabetes control (e.g. HbA1c levels), haemostatic markers or lipid profile (215218).
 i) non-insulin dependent222
 ii) insulin dependent222
c) Nephropathy/retinopathy/neuropathy232
d) Other vascular disease or diabetes of > 20 years' duration232
THYROID DISORDERS
a) Simple goitre111
b) Hyperthyroid111
c) Hypothyroid111
GASTROINTESTINAL CONDITIONS
GALL BLADDER DISEASE
a) Symptomatic
 i) treated by cholecystectomy222
 ii) medically treated222
 iii) current222
b) Asymptomatic222
HISTORY OF CHOLESTASIS*
a) Pregnancy-related111
b) Past-COC related222
VIRAL HEPATITIS